Background
Much evidence exists supporting the health benefits for women in achieving healthy lifestyle behaviours both during [
1‐
5] and following [
6‐
8] pregnancy. Adopting healthy dietary and physical activity behaviours during the postpartum period is particularly important to promote optimal maternal health, both in the short and long term. A diet adequate in fruit and vegetables and low in fat has been shown to play a vital role in reducing the risk for many diseases [
8,
9] and research has linked poor dietary habits with the development of non–communicable diseases including type 2 diabetes, hypertension, cardiovascular disease and some cancers [
10,
11]. Specifically following childbirth, healthy eating is important to adequately support breastfeeding [
12] and demonstrate healthy role modelling behaviours for infants [
12]. However it is commonplace for women of all ages not to meet dietary intake recommendations [
13]. Although some women may eat healthily during pregnancy [
14] these habits often discontinue following childbirth [
14,
15] with declines in adequacy of fruit and vegetable intake having been observed [
16‐
18].
Regular physical activity during the postpartum period has been associated with improved mental health [
6,
7] as well as improved cholesterol levels and insulin sensitivity [
6,
19], and increased chance of women returning to pre-pregnancy weight [
6,
20,
21]. Further, physical activity has been shown to be a critical influence on maternal weight [
22] and predicts postpartum weight retention (PPWR) 12 months after childbirth [
22,
23]. In the interest of maternal health, a greater understanding of physical activity patterns during the postpartum period is required, yet the literature to date suggests an observed decline in physical activity following childbirth [
5,
6,
24,
25].
Importantly, both PPWR and long term development and persistence of obesity in women [
26‐
30] have been attributed to suboptimal maternal diet and physical activity behaviours. Results from systematic reviews of interventions aimed at limiting PPWR have consistently shown that the majority of successful studies have included both diet and physical activity intervention
components in their design [
31]. Hence understanding factors which may promote healthy diet and physical activity behaviours is key to ensuring women receive the support they need to engage in these behaviours.
An important opportunity for provision of support lies with advice provided by antenatal healthcare clinicians. The antenatal period is a time in which women are in frequent contact with a wide range of health professionals [
1,
14,
32], depending on their preferred choice of antenatal care. Obstetricians, general practitioners and midwives as well as other antenatal healthcare workers are routine providers of care within the antenatal system, which in some countries has been estimated to reach almost 100 % of the pregnant population [
1,
32]. Moreover, health professionals are often viewed as authorities regarding maternal health information and advice both during [
33,
34] and following pregnancy [
35].
Compared to during pregnancy, less opportunity presents in the months following childbirth for women to be seen by healthcare practitioners. Formal, scheduled face-to-face practitioner and patient contact often occurs on fewer occasions during the postpartum period compared with during pregnancy, [
36] and formal care is inconsistent between countries. In Australia for example, there are no standardised guidelines for the recommended frequency/schedule of routine postpartum visits to healthcare providers [
37]. In the UK, however, formal guidelines such as the UK National Institute for Health and Care Excellence (NICE) recommend that diet and physical activity advice be provided to women following childbirth [
38]. The NICE guidelines also recommend a greater number of antenatal appointments with a health professional during pregnancy compared with the postpartum period [
38]. Yet, whilst some postpartum education is provided for women by nursing and other healthcare professionals, much of the support is focused on breastfeeding and care of the newborn, rather than the physical health of the mother [
39]. It is thus not surprising that primary care services for women during the postpartum period have been described as being inconsistent, fragmented across disciplines and not adequate in meeting population needs [
37,
40].
There is very little known about the diet and physical activity advice women receive during the postpartum period. A better understanding of the provision of advice and recommendations women receive and if these are associated with diet and physical activity behaviours is necessary to identify opportunities for provision of healthy lifestyle support for new mothers during this unique life stage. The aims of this study were to (i) compare the frequency of dietary and physical activity advice provided by clinicians during pregnancy and in the postpartum period and (ii) assess if advice received by women is associated with maternal postpartum diet and physical activity behaviours in a sample of first time mothers.
Discussion
This study showed that relatively few women received advice regarding diet and physical activity in the period between childbirth and 3 months postpartum. It also showed that advice during the postpartum period was less commonly received compared with during pregnancy, and that practitioner advice was not associated with healthy postpartum diet and physical activity behaviours in this sample of first time mothers.
Importantly diet and physical activity levels in this sample were inadequate overall. Only half of the women in our study were meeting recommended intakes for fruit and less than 10 % for vegetables or combined fruit/vegetable intakes. The small number of previous studies that have assessed dietary intake in mothers, have similarly shown diet quality to be suboptimal for women during the postpartum period [
14,
17]. From a public health perspective this is concerning given the well documented health benefits associated with optimal intakes with reduced chronic disease risk [
8]. Therefore strategies which assist in promoting adequate fruit and vegetable intakes in mothers are vital to ensure optimizing maternal health and wellbeing in the short and long term.
On average, time spent walking was much greater than time spent in both moderate and vigorous physical activity amongst women in this study. This is not surprising, as walking has been previously found to be the most common form of physical activity for new mothers [
58] and is a highly suitable form of physical activity for this population group. Walking is functional, low cost and low risk [
59]. Further, the health benefits associated with walking are particularly relevant to new mothers. For example, in the U.S. an intervention study conducted by Davenport et al., [
60] examined the effect of postpartum exercise intensity on chronic disease risk factors. They found that risk factors for chronic disease, including BMI, were significantly lower for women in the walking intervention groups, compared women in the control group [
60]. Furthermore, there was no additional benefit seen for women in the higher intensity walking group, suggesting that even low intensity walking on most days of the week can be beneficial for the health of a new mother during the postpartum period. Elsewhere, achieving ≥30 minutes of walking per day has been associated with the prevention of weight retention at 1 year postpartum [
25].
The results from our study showed that approximately two thirds of women engaged in physical activity which met recommendations defined as 150 min/week over ≥5 sessions, consistent with the 1999 national physical activity recommendations for Australian adults [
61]. It should be noted, however that the more recently developed national physical activity guidelines in from 2014, differ slightly to the former recommendations. Regardless, promoting physical activity during the postpartum period is an important consideration both for greater chance of supporting reductions in PPWR, when combined with dietary strategies [
31,
62], as well as assisting in the reduction of chronic disease risk.
Overall, just less than half of the sample of women in this study reported having received any dietary advice by 3 months postpartum, despite women having been shown to be particularly receptive to dietary information during the postpartum period [
63]. Women have been described as being an ideal population for receiving nutrition education (149) and in the U.S., for example, the Academy of Nutrition and Dietetics and the American Society for Nutrition recently recommended that women of reproductive age receive counselling on the importance of healthy eating including during the postpartum period [
12,
64]. It may be that a lack of formal guidelines in Australia addressing dietary advice for new mothers might in part explain why many women had not received such education by 3 months postpartum.
Furthermore, almost half of the women in this study reported that they had not received advice about physical activity by 3 months postpartum. This is consistent with findings from elsewhere, whereby many women have reported not received advice at all to be physically active during the postpartum [
65‐
67]. For example, in the U.S, Ferrari et al. (2010) assessed clinician’s provision of physical activity advice to women at 3 months postpartum [
65] and found that the majority of women (89.1 %) reported receiving no physical activity advice (77.4 %) [
65]. This omission of advice occurred against a backdrop of Institute of Medicine recommendations that physical activity counselling be included in postpartum care for all women [
68], regardless of weight status. Similarly, in the UK national guidelines recommend that women are encouraged to keep a healthy diet and be physically active during and after pregnancy [
38].
Moreover, the proportion of women who reported receiving both healthy eating advice and advice to be physically active was far less during the postpartum period compared with during pregnancy. In part, this might be due to less opportunity for women to see a healthcare practitioner during the postpartum period, for their own health as a focus, compared with during pregnancy. In the months following childbirth, a shift in focus from the health of the woman to the health of the newborn is not uncommon, making the opportunity for practitioners to engage with women regarding diet and physical activity during this time to be infrequent. Whilst it may be assumed that practitioner advice may lead to women adopting healthy behaviours, interestingly, this study showed that when advice was received, it did not predict healthy diet and physical activity behaviours. Likewise, a growing number of antenatal interventions have compared information provision (typically a brochure or meeting with health professional) with additional behaviour change strategies (such as goal setting and behavioural monitoring) and found that the information provision has very little or no impact on dietary behaviours [
69] or physical activity [
70]. Yet, other studies have shown positive associations of provision of weight advice during pregnancy, for example, with pregnancy weight gain [
71,
72].
Provision of information alone may not be sufficient to change behaviour given the many potential barriers women face to both eating healthily and being sufficiently active during and after pregnancy, including lack of time, motivation, and prioritizing their own healthy eating secondary to the demands of having a child [
33]. Strategies which account for unique barriers faced by women in the postpartum period are required. Barriers such as a lack of partner support, mothers returning to work, difficulties with childcare options and strong social expectations of the role of a new mother are also common and should be taken into account when planning supportive strategies to assist new mothers in optimizing healthy behaviours [
16,
73,
74].
In addition, perhaps alternative strategies to the mere provision of advice might be more effective in engaging postpartum women and promoting healthy behaviour change. For example, current evidence suggests that women should be supported to self-monitor their weight or set and review behavioural goals in an effort to successfully change behaviours such as increasing physical activity [
75,
76]. Techniques identified by research elsewhere during pregnancy, which have assisted healthy weight gain have included self-monitoring of behaviour, women being provided with information related to the consequences of behaviour to the individual and providing rewards contingent on successful behaviour, as well as motivational interviewing [
77]. Nonetheless, from a public health perspective, there appears to be a need to support clinicians, through alternate strategies such as lifestyle intervention programs targeting improved diet and physical activity behaviours amongst postpartum women.
A strength of this study was the assessment of frequency of advice both related to diet and physical activity. Assessing provision of advice related to both lifestyle components is important, as it has previously been shown that lifestyle changes, including both dietary intake and physical activity in combination, are more likely to be successful in minimizing PPWR for example, rather than one behavior alone [
31,
62,
78,
79]. Therefore understanding predictors of these behaviours is key to addressing opportunities for behavior change. A further strength of this study was comparison of the reported advice received during and following pregnancy. This comparison allows identification of gaps in current management strategies to be made, and showed that the postpartum period can be considered a missed opportunity at present, for provision of healthy lifestyle advice, thereby supporting the need for greater provision of support in the months following childbirth.
The main limitation of this study was the inability to determine what specific advice regarding weight, diet or physical activity was provided to women. This is an important consideration, for example regarding gestational weight gain, as when healthcare practitioners do use target weights for women as part of their practice, studies have shown that women often adhere to guidelines [
71,
80,
81]. Provision of non-specific advice, such as clearly defined fruit and vegetable recommendations or physical activity recommendations, may have been one reason why no associations with advice and healthy lifestyle behaviours was seen, yet this is unable to be determined. Further, this sample of women were predominately highly educated and over half of the sample of women had moderate to high household income therefore limiting the generalizability of the results. Future research would ideally consider practitioner lifestyle advice provided to low income women to enable specific delivery of postpartum support amongst different population groups following childbirth.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
PV and KC conceived this study and KC, KB, KH and DC advised on the study design. PV assisted with study recruitment, data collection and conducted the statistical analysis. PV drafted the manuscript together with EO. All authors contributed to the critical revision of the paper and approved the final manuscript.